Healthcare Provider Details

I. General information

NPI: 1861449118
Provider Name (Legal Business Name): EUSEBIO A. DIAZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SIERRA DE CAYEY PLAZA SUITE 207 AVE. ANTONIO R. BARCELO
CAYEY PR
00736
US

IV. Provider business mailing address

PO BOX 7859
CAGUAS PR
00726-7859
US

V. Phone/Fax

Practice location:
  • Phone: 787-263-7500
  • Fax:
Mailing address:
  • Phone: 787-381-8635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1003
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: